Adult Family Home Renewal Of Certification printable pdf download

Adult Family Home Renewal Of Certification

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Long Term Care

F-20439 (08/2008)

ADULT FAMILY HOME (AFH) RENEWAL OF CERTIFICATION

GRANDFATHERING REQUEST

Completion of this form is voluntary. Failure to complete this form may result in delayed processing of the request.

Return completed forms to: Carrie Molke, LTC Residential Policy Specialist, Bureau of Long-Term Support via fax:

608-267-2913, e-mail: Carrie.Molke@dhs.wisconsin.gov, or via mail: P. O. Box 7851, Madison 53707-7851.

County

Date of Request

Name of Person Completing Request

Title

Telephone Number

Fax Number

E-Mail Address

Name of Adult Family Home

Date Certified as AFH

Address

City

State

Zip Code

Name of Participant

Date Entered AFH

Explain the situation and reason why grandfathering is necessary

Explain the consequence if grandfathering is not granted

Explain how you have attempted to comply with the new standards

Explain how health and safety will be assured

Department Use Only

Approved

—

Denied

Reason: _______________________________________________________________

Date

__________________________

Adult Family Home Renewal Of Certification